[Code of Federal Regulations]
[Title 12, Volume 1]
[Revised as of January 1, 2003]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR438.310]

[Page 219]
 
                         TITLE 42--PUBLIC HEALTH
 
  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 
                 HEALTH AND HUMAN SERVICES--(Continued)
 
PART 438--MANAGED CARE--Table of Contents
 
                   Subpart E--External Quality Review
 
Sec. 438.310  Basis, scope, and applicability.

    Source: 68 FR 3635, Jan. 24, 2003, unless otherwise noted.


    (a) Statutory basis. This subpart is based on sections 1932(c)(2), 
1903(a)(3)(C)(ii), and 1902(a)(4) of the Act.
    (b) Scope. This subpart sets forth requirements for annual external 
quality reviews of each contracting managed care organization (MCO) and 
prepaid inpatient health plan (PIHP), including--
    (1) Criteria that States must use in selecting entities to perform 
the reviews;
    (2) Specifications for the activities related to external quality 
review;
    (3) Circumstances under which external quality review may use the 
results of Medicare quality reviews or private accreditation reviews; 
and
    (4) Standards for making available the results of the reviews.
    (c) Applicability. The provisions of this subpart apply to MCOs, 
PIHPs, and to health insuring organizations (HIOs) that began on or 
after January 1, 1986 that the statute does not explicitly exempt from 
requirements in section 1903(m) of the Act.